Rethinking Everything We Thought About Addiction

Years of scientific study have taught us that addiction is a chronic brain disease. But compared to medical and technological breakthroughs for other chronic diseases, such as type 2 diabetes, advances in drug and alcohol treatment haven’t kept pace. Despite a wide range of recovery options, relapse rates remain high. Across the globe, the number of alcohol and drug addicts continues to rise every year.

There is an urgent need to improve treatment as well as increase access to quality care. To achieve these goals, we need to understand how the latest scientific evidence challenges long-standing beliefs about addiction and how we treat it.

Under normal circumstances, our bodies react to naturally occurring stimuli, such as eating and sex, by sending pleasure signals to our brains. Our brains have evolved to interpret eating and sex as pleasurable pursuits because they have ensured the survival of our species. When we engage in activities like these, dopamine, a neurotransmitter, is released into the nucleus accumbens (commonly called our brain’s pleasure center) and voila! We feel good. Similarly, addictive substances cause pleasure by flooding the nucleus accumbens with dopamine. But addictive drugs typically release 2 to 10 times more dopamine than their naturally occurring counterparts.

Armed with these understandings, most in the scientific and medical communities concluded that the release of dopamine into our brain’s pathways was entirely, or at least largely, responsible for the reinforcing effects of drugs. The so-called dopamine hypothesis explained how the pleasure caused by drugs led to repetition of behaviors that prompted feelings of euphoria, satisfaction, and pleasure.

Going Beyond the Dopamine Hypothesis

If dopamine is the primary driver of addiction, then anyone who uses drugs should become addicted, and all addictive drugs should be interchangeable. But science is showing that neither is the case. In fact, less than 10% of people who use alcohol and other drugs become addicted, and addictive substances are not interchangeable. For example, nicotine isn’t a substitute for heroin, marijuana doesn't take the place of cocaine, and alcohol is not a replacement for amphetamines. Thus pleasure can’t be the sole cause of addiction.

Thanks to quantum leaps in brain imaging technology, experts at the forefront of the science of addiction recognize that alcohol and other drugs, over time, cause physical changes in different parts of the brain. For instance, drugs affect brain regions that influence learning, memory, feelings, and mood. New studies continually show that it’s these changes that cause addicts to become obsessed with their drug of choice.

Although drug use begins with the activation of the brain’s dopamine pleasure pathway, it also alters other parts of the brain. Together, these often result in addiction. Thus, activation of the brain’s pleasure center is the primary starting point of addiction. But once a person takes drugs habitually, their use affects other brain regions. And these areas have little to do with the rewarding influence of drugs.

New Interpretations of Current Treatment Methods

So how do we use this information to improve how we treat addicts? First, we must reevaluate past approaches. For instance, many healthcare professionals believed that controlling dopamine levels in addicts could decrease, or even cure, addiction. But more than 20 years of research have repeatedly shown that treatments primarily focused on dopamine levels aren’t effective. Although controlling dopamine levels addresses how addiction starts, it doesn’t tackle the reasons behind long-term drug abuse. So the question becomes what treatment approaches can provide the best possible outcome for the most people?

Herein lies the intersection between tried and true 12-Step principles and scientifically and medically based approaches. We now understand that addiction cannot be reduced merely to dopamine dependence. In fact, 12-Step programs, such as Alcoholics Anonymous, are effective precisely because they address the changes that take place in other areas of the brain that influence addiction.

Both groups — the 12-Steppers and the scientific community — need to learn from one another to provide the best of both worlds in treatment. Twelve-Steppers shouldn’t disregard scientific advances that change how we treat addiction, but the scientific community shouldn’t underestimate the importance of the Steps in remedying memory deficits and rebuilding a connection to the community through empathy and service.

When the strengths of both 12-Step and the scientific and medical communities merge, addicts have treatment options that can provide faster, longer-lasting recovery.

David Sack, M.D., is board certified in Addiction Medicine and Addiction Psychiatry. As CEO of Elements Behavioral Health he oversees a number of addiction treatment centers. He served as a senior clinical scientist at the National Institute of Mental Health (NIMH) where his research interests included affective disorders, seasonal and circadian rhythms,and neuroendocrinology. You can follow Dr. Sack on Twitter.

Fascinating data! I am a long time member of two 12 step programs. I find being with others and hearing their truth enormously healing. Knowing i am not alone is the biggest benefit. Will you say more about the areas of the brain that 12 step programs effect?

Interesting ideas. I'd like to see more info about something that I've personally seen that doesn't seem to get acknowledged much in the wider world of media - that individual predilection to addiction varies widely. I've used alcohol and tobacco regularly, and never felt like I needed to have more of it. I've used marijuana dozens of times, and cocaine like 5-10 times, and never felt like I needed more of either of them. I haven't really tried to get myself hooked on anything, but I'm pretty sure I'm just not inclined to get addicted to things and that it would be very difficult for me to do so.

I do understand, though, that some people do have a strong tenancy to get addicted to things, and if you're like that, you'd best not even try any of those drugs.

I think that we're doing the world a disservice with the message that anyone who touches any of these drugs will immediately become hopelessly addicted. It's only true for a small number of people, and when anyone who it isn't true for finds out that it's wrong, their respect for all messages about drugs is destroyed.

Dude it just amazes me how many people in this world are in Denial brother and in my opinion you are one of them. if that is what you believe than you should try Celebrate Recovery it's a 12 step program that deals not just with drug addiction but also co-dependency among any hurt, habit, and hang-up one might have and brother once again my opinion yea you need to admit you have a problem..If anyone took your advise the addiction rate would climb beyond limit. Please visit celebraterecovery.com for more info on help.

The statistics and erroneous data a quite misleading. There are far more addicts that the statistics suggest and the 12 step program at AA is not very successful if you add in to the equation addiction transference, replacing one addiction with the other.
The Set Point theory of addiction accounts for the variations in the types and amounts of different drugs of abuse. The mainstream view of addiction is very limited and only accounts for the extreme end of the scale.
Addiction should be defined as a continual behaviour that causes harm to the organism and despite such harm the release of mental tension and gratification overrides the self preservation mechanism via a neurochemical imbalance that creates a deficiency of such chemicals and a mental dependence/attachment to the substance of abuse.
There are many types of addicts with all different set points from daily, weekly and monthly users. If one can stay six months clean from whether it be heroin, coffee, starch, meat, nicotine, refined sugar etc etc one will see the difference in mental clarity and improvements in health and mental well being.

The statistics and erroneous data are quite misleading. There are far more addicts that the statistics suggest and the 12 step program at AA is not very successful if you add in to the equation addiction transference, replacing one addiction with the other.
The Set Point theory of addiction accounts for the variations in the types and amounts of different drugs of abuse. The mainstream view of addiction is very limited and only accounts for the extreme end of the scale.
Addiction should be defined as a continual behaviour that causes harm to the organism and despite such harm the release of mental tension and gratification overrides the self preservation mechanism via a neurochemical imbalance that creates a deficiency of such chemicals and a mental dependence/attachment to the substance of abuse.
There are many types of addicts with all different set points from daily, weekly and monthly users. If one can stay six months clean from whether it be heroin, coffee, starch, meat, nicotine, refined sugar etc etc one will see the difference in mental clarity and improvements in health and mental well being.

How do you replace the pleasure that the addict receives from whatever substance of choice has resuted in the addictive behavior? My research has shown that this is where the 12 steps comes into play. The emphathy and gratifications that comes from helping others while helping themselves provides purpose and eventually replaces the good feelsings that was once achieved from the substance usage.

There is a difference between true joy and the pleasure obtained from the mental release of tension through self medicating via drugs or drug-foods. When you clear the mind of toxins one will find that happiness is a true state of being and secondary to love.

The AA does help people come to terms with their addiction and finds an outlet for them to express that which is within in a safe manner however a true test of an addict is to give up all that is bad for them on every level. Why not just break the cycle of addiction once and for all instead of replacing the thing that one is addicted to ie the feeling derived from such behaviour with another behaviour?

The AA helped me tremendously in the past but it is not without limitations and I am yet to find another clean person in the rooms. That is someone who eats and lives in accord with nature to the best of their ability.
If we adhere to natures principles/laws our natural state of being and self preservation is self-love, without this not a single species on the planet would have evolved.

Negative emotions are an illusion of the mind and all pain is self created. When one takes responsibility for creating the good and bad emotions in their lives and pays attention to how they make them behave one will eventually transcend dualistic thinking and polarised emotions once and for all if their heart truly desires it.

Have they tested saliva and urine samples of a group of social drinkers and a group of alcoholics before and after imbibing to see if there's a difference in their digestive systems?
Maybe there's an enzyme deficiency in alcoholics. Perhaps the cure is something really simple, like eating pickled eggs, we're missing it because the problems are so huge. ... "the smallest thorn pierces the deepest"

First I want say how refreshing this article is to me. As a former AA member, I agree that 12-Steppers and the scientific community need to learn from one another. I have been sober over 16 years now, and I have learned more about addiction on my own than I did in AA.

However, for the first 8 years of my sobriety going to meetings and practicing The 12 Steps certainly changed my thought processes. Once I began thinking in a new and different way, I was able to see life differently. I also grew strong enough to find greater happiness on my own over that time.

Today, I can clearly relate to what this article is saying. Not only has science and medicine helped me to understand addiction, but it also helped me to understand myself more.

I have hope that 12 Step and scientific and medical communities will merge some day and find faster, long lasting recovery, but how society still views addiction will have to change first. For that to happen, it will be essential for people to have an open mind and become convinced that change can do us good.

Dear David Sack, I think you should clearly point out that an A.A. group is an anonymous peer support group and NOT an evidence-based treatment modality.

When will medical professionals and writers of magazine articles stop characterizing an A.A. group as providing "treatment."

The people in these groups have absolutely no professional training, no professional credentials nor any licences to provide treatment for any type of illness or disease.

When someone who has hearing loss or vision loss or diabetes or heart disease or cancer is referred to a social support group, do we say they are in "treatment" and start comparing the effectiveness of what the social group provides to the effectiveness of the medical treatment provided by the health care system, doctors and counselling professionals? No. Only in the world of addiction medicine is a social group considered the equivalent of paid medical treatment.

It's time to stop saying that A.A.groups(or any other XA group)provide "treatment." They are social groups that provide social support. The majority of the members of these groups are religious. Non-religious people who join a group should keep in mind that they are welcome, but only to the same extent that non-believers were always welcomed into a Billy Graham crusade.

The characteristics of an A.A. group are the same as most religious groups. In the A.A. fellowship the majority of people behave religiously - praying together publicly to their Higher Power, seeking their Higher Power, talking about their Higher Power in and out of meetings. The non-religious are only "guests." They cannot become true members of the religious fellowship without adopting some type of substitute for God i.e. the Higher Power. Non-professional "counselors" in these groups will tell newcomers that they need to find a substitute God, even if that is a doorknob or a rock. How ridiculous for medical professionals and journalists to characterize this religious "counseling" as "treatment."

Your blog says: "but the scientific community shouldn’t underestimate the importance of the Steps in remedying memory deficits and rebuilding a connection to the community through empathy and service." The "steps" do not do anything. They are inanimate words on a piece of paper. It is participation in a social group that may eventually cause the changes you describe. If, and that is a big IF, the person can handle the religious environment and the religious social pressure from the group.

Again, almost all A.A. groups are religious social groups, so why do people continue to say these groups are providing "treatment?"